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Tuesday, 14 May 2019

Making best use of existing NKCC1/2 Blockers in Autism






Azosemide C12H11ClN6O2S2  


Today’s post may be of interest to those already using bumetanide for autism and for those considering doing so.  It does go into the details, because they really do matter and does assume some prior knowledge from earlier posts.

There has been a very thorough new paper published by a group at Johns Hopkins:-
It does cover all the usual issues and raises some points that have not been covered yet in this blog.  One point is treating autism prenatally. This issue was studied twice in rats, and the recent study was sent to me by Dr Ben Ari.  Short term treatment during pregnancy produced a permanent benefit.

Maternal bumetanide treatment prevents the overgrowth in the VPA condition

            
Brief maternal administration of bumetanide before birth restores low neuronal intracellular chloride concentration ([Cl]i) levels, produces an excitatory-to-inhibitory shift in the action of γ-aminobutyric acid (GABA), and attenuates the severity of electrical and behavioral features of ASD (9, 10), suggesting that [Cl]i levels during birth might play an important role in the pathogenesis of ASD (7). Here, the same bumetanide treatment significantly reduced the hippocampal and neocortical volumes of P0 VPA pups, abolishing the volume increase observed during birth in the VPA condition [hippocampus: P0 VPA versus P0 VPA + BUM (P = 0.0116); neocortex: P0 VPA versus P0 VPA + BUM (P = 0.0242); KWD] (Fig. 3B). Maternal bumetanide treatment also shifted the distribution of cerebral volumes from lognormal back to normal in the population of VPA brains, restoring smaller cerebral structure volumes (Fig. 3C). It also decreased the CA3 volume to CTL level after birth, suggesting that the increased growth observed in this region could be mediated by the excitatory actions of GABA (Fig. 3D). Therefore, maternal bumetanide administration prevents the enhanced growth observed in VPA animals during birth.

One issue with Bumetanide is that it affects both:-

·        NKCC2 in your kidneys, causing diuresis
·        NKCC1 in your brain and elsewhere, which is divided into two slightly different forms NKCC1a and NKCC1b

NKCC1 is also expressed in your inner ear where it is necessary for establishing the potassium-rich endolymph that bathes part of the cochlea, an organ necessary for hearing. 

If you block NKCC1 too much you will affect hearing.

Blocking NKCC1 in children and adults is seen as safe but the paper does query what the effect on hearing might be if given prenatally as the ear is developing.

Treating Down Syndrome Prenatally

While treating autism prenatally might seem a bit unlikely, treating Down Syndrome (DS) prenatally certainly is not.  Very often DS is accurately diagnosed before birth creating a valuable treatment window.  In most countries the vast majority of DS prenatal diagnoses lead to termination, but only a small percentage of pregnancies are tested for DS. In some countries such as Ireland a significant number of DS pregnancies are not terminated, these could be treated to reduce the deficits that will otherwise inevitably follow.



The research does suggest that DS is another brain disorder that responds to bumetanide.


Back to autism and NKCC1

This should remind us that a defect in NKCC1 expression will not only cause elevated levels of chloride with in neurons, but will also affect the levels of sodium and potassium with neurons.

There are many ion channel dysfunctions (channelopathies) implicated in autism and elevated levels of sodium and potassium will affect numerous ion channels.  The paper does suggest that the benefit of bumetanide may go beyond modifying the effect of GABA, which is the beneficial mode of action put forward by Dr Ben Ari.
We have seen how hypokalemic sensory overload looks very similar to what often occurs in autism and that autistic sensory overload is reduced by taking an oral potassium supplement.

The paper also reminds us that loop diuretics like bumetanide and furosemide not only reduce inflow of chloride into neurons, but may also reduce the outflow. This is particularly known of furosemide, but also occurs with bumetanide at higher doses.
The chart below shows that the higher the concentration of bumetanide the strong its effect becomes on blocking NKCC1.


But at higher doses there will also be a counter effect of closing the NKCC2 transporter that allows chloride to leave neurons.
At some point a higher dose of bumetanide may have a detrimental effect on trying to lower chloride within neurons.

Since Dr Ben Ari’s objective is to lower chloride levels in neurons  it is important how freely these ions both enter and exit.  The net effect is what matters. (Loop diuretics block NKCC1 that lets chloride enter neurons but also block the KCC2 transporter via which they exit)

Is Bumetanide the optimal existing drug to lower chloride within neurons?  Everyone agrees that it is not, because only a tiny amount crosses into the brain. The paper gives details of the prodrugs like BUM5 that have been looked at previously in this blog; these are modified versions of bumetanide that can better slip across the blood brain barrier and then react in the brain to produce bumetanide itself.  It also highlights the recent research that suggests that Bumetanide may not be the most potent approved drug, it is quite conceivable that another old drug called Azosemide is superior.

The blood brain barrier is the problem, as is often the case.  Bumetanide has a low pH (it is acidic) which hinders its diffusion across the barrier.  Only about 1% passes through.

There is scepticism among researchers that enough bumetanide can cross into the brain to actually do any good.  This is reflected in the review paper.

The paper reminds us of the research showing how you can boost the level of bumetanide in the brain by adding Probenecid, an OAT3 inhibitor.  During World War 2 antibiotics were in short supply and so smaller doses were used, but their effect was boosted by adding Probenecid. By blocking OAT3, certain types of drug like penicillin and bumetanide are excreted at a slower rate and so the net level in blood increases.

The effect of adding Probenecid, or another less potent OAT3 inhibitors, is really no different to just increasing the dose of bumetanide.

The problem with increasing the dose of bumetanide is that via its effect on NKCC2 you cause even more diuresis, until eventually a plateau is reached.

Eventually, drugs selective for NKCC1a and/or NKCC1b will appear.

In the meantime, the prodrug BUM5 looks good. It crosses the BBB much better than bumetanide, but it still affects NKCC2 and so will cause diuresis.  But BUM5 should be better than Bumetanide + Probenecid, or a higher dose of Bumetanide.  BUM5 remains a custom-made research drug, never used in humans.

I must say that what again stands out to me is the old German drug, Azosemide.

In a study previously highlighted in this blog, we saw that Azosemide is 4 times more potent than Bumetanide at blocking NKCC1a and NKCC1b.

Azosemide is more potent than bumetanide and various other loop diuretics to inhibit the sodium-potassium-chloride-cotransporter human variants hNKCC1A and hNKCC1B

Azosemide is used in Japan, where recent research shows it is actually more effective than other diuretics

Azosemide, a Long-acting Loop Diuretic, is Superior to Furosemide in Prevention of Cardiovascular Death in Heart Failure Patients Without Beta-blockade 

As is often the case, Japanese medicine has taken a different course to Western medicine.

Years of safety information has already been accumulated on Azosemide.  It is not an untried research drug. It was brought to market in 1981 in Germany. It is available as Diart in Japan made by Sanwa Kagaku Kenkyusho and as a cheaper generic version by Choseido Pharmaceutical. In South Korea Azosemide is marketed as Uretin.


In any other sector other than medicine, somebody would have thought to check by now if Azosemide is better than Bumetanide.  It is not a matter of patents, Ben-Ari has patented all of the possible drugs, including Azosemide and of course Bumetanide.

So now we move on to Azosemide.



When researchers came to check the potency of the above drugs the results came as a surprise.  It turns out that the old German drug Azosemide is 4 times as potent as bumetanide.






The big question is how does it cross the blood brain barrier.


“The low brain concentrations of bumetanide obtained after systemic administration are thought to result from its high ionization (>99%) at physiological pH and its high plasma protein binding (>95%), which restrict brain entry by passive diffusion, as well as active efflux transport at the blood-brain barrier(BBB). The poor brain penetration of bumetanide is a likely explanation for its controversial efficacy in the treatment of brain diseases

“… azosemide was more potent than any other diuretic, including bumetanide, to inhibit the two NKCC1 variants. The latter finding is particularly interesting because, in contrast to bumetanide, which is a relatively strong acid (pKa = 3.6), azosemide is not acidic (pKa = 7.38), which should favor its tissue distribution by passive diffusion. Lipophilicity (logP) of the two drugs is in the same range (2.38 for azosemide vs. 2.7 for bumetanide). Furthermore, azosemide has a longer duration of action than bumetanide, which results in superior clinical efficacy26 and may be an important advantage for treatment of brain diseases with abnormal cellular chloride homeostasis.”


Dosage equivalents of loop Diuretics


Bumetanide has very high oral bioavailablity, meaning almost all of what you swallow as a pill makes it into your bloodstream.

Furosemide and Azosemide have much lower bioavailability and so higher doses are needed to give the same effect.

Both Furosemide and Bumetanide are short acting, while Azosemide is long acting.

For a drug that needs to cross the blood brain barrier small differences might translate into profoundly different effects.

The limiting factor in all these drugs is their effect on NKCC2 that causes diuresis.

1mg of bumetanide is equivalent to 40mg of furosemide.
2mg of bumetanide is equivalent to 80mg of furosemide.

The standard dose for Azosemide in Japan, where people are smaller than in the West, is 30 mg or 60mg. 

Research suggests that the same concentration of Azosemide is 4x more potent than Bumetanide at blocking NKCC1 transporters, other factors that matter include:-

·        How much of the oral tablet ends up in the bloodstream.
·        How long does it stay in the blood stream
·        How much of the drug actually crosses the blood brain barrier
·        How does the drug bind to the NKCC1 transporters in neurons
·        How rapidly is the drug excreted from the brain
·        What effect is there on the KCC2 transporter that controls the exit of chloride ions from neurons.

All of this comes down to which is more effective in adults with autism 2mg of bumetanide or 60mg of Azosemide.

The side effects, which are mainly diuresis and loss of electrolytes will be similar, but Azosemide is a longer acting drug and so there will be differences. In fact Azosemide is claimed to be less troublesome than Bumetanide in lower potassium levels in your blood.

Conclusion  

The open question is whether generic Azosemide is “better” than generic Bumetanide for treating brain disorders in humans.

I did recently ask Dr Ben-Ari if he is aware of any data on this subject. There is none.

Many millions of dollars/euros are being spent getting Bumetanide approved for autism, so it would be a pity if Azosemide turns out to be better. (Dr Ben Ari’s company Neurochlore wants to develop a new molecule that will cross the blood brain barrier, block NKCC1 and not NKCC2 and so will not cause diuresis).

The hunch of the researchers from Hanover, Germany seems to be that the old German drug Azosemide will be better than Bumetanide.

I wonder if doctors at Johns Hopkins / Kennedy Krieger have started to prescribe bumetanide off-label to their patients with autism.  Their paper shows that they have a very comprehensive knowledge of the subject.


===========

I suggest readers consult the full version of the Johns Hopkins review paper on Bumetanide, it is peppered with links to all the relevant papers.

Bumetanide (BTN or BUM) is a FDA-approved potent loop diuretic (LD) that acts by antagonizing sodium-potassium-chloride (Na-K-Cl) cotransporters, NKCC1 (SLc12a2) and NKCC2. While NKCC1 is expressed both in the CNS and in systemic organs, NKCC2 is kidney-specific. The off-label use of BTN to modulate neuronal transmembrane Clgradients by blocking NKCC1 in the CNS has now been tested as an anti-seizure agent and as an intervention for neurological disorders in pre-clinical studies with varying results. BTN safety and efficacy for its off-label use has also been tested in several clinical trials for neonates, children, adolescents, and adults. It failed to meet efficacy criteria for hypoxic-ischemic encephalopathy (HIE) neonatal seizures. In contrast, positive outcomes in temporal lobe epilepsy (TLE), autism, and schizophrenia trials have been attributed to BTN in studies evaluating its off-label use. NKCC1 is an electroneutral neuronal Climporter and the dominance of NKCC1 function has been proposed as the common pathology for HIE seizures, TLE, autism, and schizophrenia. Therefore, the use of BTN to antagonize neuronal NKCC1 with the goal to lower internal Cl levels and promote GABAergic mediated hyperpolarization has been proposed. In this review, we summarize the data and results for pre-clinical and clinical studies that have tested off-label BTN interventions and report variable outcomes. We also compare the data underlying the developmental expression profile of NKCC1 and KCC2, highlight the limitations of BTN’s brain-availability and consider its actions on non-neuronal cells.

Btn Pro-Drugs and Analogs

To improve BTN accessibility to the brain, pro-drugs with lipophilic and uncharged esters, alcohol and amide analogs have been created. These pro-drugs convert to BTN after gaining access into the brain. There was a significantly higher concentration of ester prodrug, BUM5 (N,N – dimethylaminoethyl ester), in mouse brains compared to the parent BTN (10 mg/kg, IV of BTN and equimolar dose of 13 mg/kg, IV of BUM5) (Töllner et al., 2014). BUM5 stopped seizures in adult animal models where BTN failed to work (Töllner et al., 2014Erker et al., 2016). BUM5 was also less diuretic and showed better brain access when compared to the other prodrugs, BUM1 (ester prodrug), BUM7 (alcohol prodrug) and BUM10 (amide prodrug). BUM5 was reported to be more effective than BTN in altering seizure thresholds in epileptic animals post-SE and post-kindling (Töllner et al., 2014). Furthermore, BUM5 (13 mg/kg, IV) was more efficacious than BTN (10 mg/kg, IV) in promoting the anti-seizure effects of PB, in a maximal electroshock seizure model (Erker et al., 2016). Compared to BUM5 which was an efficacious adjunct to PB in the above mentioned study, BTN was not efficacious when administered as an adjunct (Erker et al., 2016). In addition to seizure thresholds, further studies need to be conducted to assess effects of BUM5 on seizure burdens, ictal events, duration and latencies.
Recently, a benzylamine derivative, bumepamine, has been investigated in pre-clinical models. Since benzylamine derivatives lack the carboxylic group of BTN, it results in lower diuretic activity (Nielsen and Feit, 1978). This prompted Brandt et al. (2018) to explore the proposed lower diuretic activity, higher lipophilicity and lower ionization rate of bumepamine at physiological pH. Since it is known that rodents metabolize BTN quicker than humans, the study used higher doses of 10 mg/kg of bumepamine similar to their previous BTN studies (Olsen, 1977Brandt et al., 2010Töllner et al., 2014). Bumepamine, while only being nominally metabolized to BTN, was more effective than BTN to support anticonvulsant effects of PB in rodent models of epilepsy. This GABAergic response, however, was not due to antagonistic actions on NKCC1; suggesting bumepamine may have an off-target effect, which remains unknown. However, the anticonvulsive effects of bumepamine, in spite of its lack of action on NKCC1, are to be noted. Additionally, in another study by the same group, it was shown that azosemide was 4-times more potent an inhibitor of NKCC1 than BTN, opening additional avenues for better BBB penetration and NKCC1-antagonizing compounds for potential neurological drug discovery (Hampel et al., 2018).

Conclusion


The beneficial effects of BTN reported in cases of autism, schizophrenia and TLE, given its poor-brain bioavailability are intriguing. The mechanisms underlying the effects of BTN, as a neuromodulator for developmental and neuropsychiatric disorders could be multifactorial due to prominent NKCC1 function at neuronal and non-neuronal sites within the CNS. Investigation of the possible off-target and systemic effects of BTN may help further this understanding with the advent of a new generation of brain-accessible BTN analogs.




42 comments:

  1. Dear All,
    does anyone have the experience of using ketone test strip to test ketouria?
    Before the dinner today we gave 5 g ( 8-9 ml) HVMN + 10 ml C8 to our boy, after 40 min ketone test strip reading was 0. then we gave +7.5 ml KF + 10ml C8, and waited 6 min and tested again, again there was almost no ketouria, the reading was zero or close to trace. I thought the dosage should be sufficient.
    Yi

    ReplyDelete
    Replies
    1. Yi, perhaps the more reliable way to check ketosis in the ketone ester users is BHB blood level meter. You check acetoacetate with urine strips, so that can only be a proxy for BHB level.

      On the other hand my son reached 0,5-1,5 mmol/l readings on the Keto Diastix urine strips when he was on Keto Force but null on relevant dose of ketone ester. Keto Diastix reading was 4 mmol/l recently during fever, so the strips are ok.
      The behavioral/cognitive effect of BHB salts and ester seem similar, so it is confusing.

      Has anyone more used the ketone esters? Could you share your experience? AJ, what is your opinion?

      Delete
    2. Dear Agnieszka, and Dear all.
      I contacted an expert in Keto ester (a senior MD/PhD in a major institution in USA). He recommends 20g twice a day for adults - ( when I inquired, I did not specify it was for child. I did not specify it was intended for ASD)
      So 5 g daily may be a too small dosage even for a child
      Yi

      Delete
    3. I had been wondering about keto ester /HVMN
      --------------------
      If I understand correctly, I realized that the advantage of keto ester /HVMN is that it could be administered in large quantity, rather than it has other advantages over Ketoforce (KF).
      If 20g * 2 BHB/day is needed for an adult, then maybe 20g BHB/day is sufficient for a child (depending on the body weight).
      KF marks that 3 caps (= 7.5 ml*3, this is the recommended serving ) has 11.5 g BHB, then 20g BHB/day can be approximately achieved by 3 caps KF + 5g BHB of keto ester + > 20ml C8 oil.
      Thus 20g BHB/day is achievable.
      On the other hand, it occurs to me that keto ester /HVMN may not be very cost-effective if the goal is 20g BHB/day for a long duration.

      Delete
    4. Further to my previous messages, I found that with 15ml of Ketoforce + 10 ml of C8 oil, the keto testing strip worked.
      as Agnieszka noted, keto testing strip seems does not work for kester este very well.

      Delete
    5. Yi and others

      Blood testing of ketones measures β-hydroxybutyrate. Urine testing of ketones measures acetoacetate. It is assumed that there is a correlation between the two, it well known not to be a reliable one.

      If you want to know BHB levels, rather than a possibly unreliable proxy for them, you have to test blood samples.

      It may be the ketone esters do not produce acetoacetate, that may well make them more effective. C8 will produce acetoacetate.

      At the end of the day the objective is to produce BHB, some of which will be consumed as fuel by mitochondria. The object is not to produce expensive urine laden with expensive BHB.

      Blood β-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: a systematic review.
      https://www.ncbi.nlm.nih.gov/pubmed/23330615

      Delete
  2. Yi- I have a few years experience with my son on the diet. When we first started the diet it took a while for the strips to show a reading it was 3-4 days but I was told it could be up to a week to reach a therapeutic level on the strips. Another thing was the ketones during the course of a day. The ketones should be a little lower in the AM and higher by the afternoon.

    Also, storage of ketone strips is important. Keep them out of humid areas, away from light, and not in a very hot environment.

    Also, once the ketones are consistent and you find out that your child has slipped or someone gave your child something with sugar -this will quickly drop the ketones but because you are established on the diet it is easier to then bounce back with a dose of whatever fat you are using or fat bombs. For fat bombs I like to make things with cocoa butter. It has oleic and stearic acids which are beneficial for him.

    The longer they are out of ketosis the longer it takes to get back. But at the same time you don't want to rush it because you don't want to deal with keto flu especially if new to it or re starting.

    The other thing is to push fluids and electrolytes especially if you are in a hot place like we are. My son sweats a lot and the diet increases urination.

    https://shop.bodybio.com/products/e-lyte-balanced-electrolyte-concentrate

    ReplyDelete
    Replies
    1. Thank you.
      and There was a typo in my post, it should be 'and waited 60 min and tested again,'

      Delete
  3. Also, I am not sure how old your son is but I find that putting fat bombs in the freezer and anything frozen is just more fun

    ReplyDelete
  4. petra petra, How you managed to get bumetanide tablets for your son in Greece.

    ReplyDelete
  5. Anonymous, I got a prescription from a pneumonologist and bought bumetanide from pharmacies in Serbia.

    Peter,this papers says Bumetanide could be used as a prophylactic treatment to reduce neurological and psychiatric consequences of human adult brain trauma induced depression and cognitive deficits associated with an impairment of post traumatic secondary neurogenesis within the dentate gyrus of the hippocampus.
    https://www.ncbi.nlm.nih.gov/pmc/.../PMC6370740/ -
    Petra

    ReplyDelete
    Replies
    1. Petra, it seems that a disturbed chloride balance is a feature of many conditions. Some even appear to be unrelated to an imbalance in NKCC1 and KCC2, such as in Dravet Sydrome where Bumetanide improves seizures etc, but NKCC1/KCC2 appeared normal.

      Delete
    2. Peter Lloyd-Thomas, what intervention is indicated specifically for Stereotypy and Thought Process issues. Potent microglia inhibition with lamotrigine add on partly ameliorates these nasty symptoms but it's far from enough to achieve optimal functional outcomes.

      Delete
    3. Unfortunately, unlike many common medical issues where each symptom has a therapy, this is usually not the case with brain disorders.

      In my son NAC is effective with 30 minutes at reducing stereotypy, but in other people it has no effect. I believe people often confuse stereotypy with tics. Tics are something completely different.

      Some people's stereotypy is a manifestation of anxiety, which itself has numerous biological and behavioral causes. In some people targeting anxiety or indeed ADHD ends up making stereotypy go away.

      There are no simple answers, but people who persevere often find an effective solution.

      Delete
  6. Currently using minocycline as a microglia inhibitor ^

    ReplyDelete
  7. Not to stir up too much controversy, but some interesting research suggests that eating whole grain rye bread lowers blood serotonin levels:

    Press Release:

    https://www.sciencedaily.com/releases/2019/05/190513100605.htm

    Paper:

    https://academic.oup.com/ajcn/advance-article-abstract/doi/10.1093/ajcn/nqy394/5480604?redirectedFrom=fulltext

    The reason I speak of controversy is that pursuing a gluten-free casein-free diet may actually be harmful to some people with autism, considering one of the most reliably reproduced and oldest metabolomic profiles of autism is elevated blood plasma serotonin levels, and this research suggests that whole grains, and in particular whole grain rye bread, decreases blood plasma serotonin levels. Excess blood plasma serotonin contributes to peripheral inflammation which is generally not good, though it is still unclear if elevated blood plasma symptoms are a cause or effect of the autism phenotype.

    ReplyDelete
  8. More news on clemastine to do with brain cancer

    https://www.sciencedaily.com/releases/2019/05/190510094804.htm

    ReplyDelete
  9. Hi Peter,

    We are currently on the second month of our Bumetanida trial for our 5yo daughter. We have had a couple of wow moments but it’s difficult to say if it’s from the medication or from her therapy. Our French Dr who is involved in the trials has said that this is not an unusual situation to have slow progress and to keep going to the 3 month mark before drawing a conclusion.

    Interestingly there has been no diuretic effect what so ever. Do you think this explain the slow or non existent cognitive effect that we are seeing?

    ReplyDelete
    Replies
    1. Kei, there should be a diuretic effect. The diuretic effect is the limiting factor on the dosage. I would try a higher dose.

      Delete
  10. Speaking about Japanese medicine, does anyone know traditional Kampo medicine remedy for autism? It is called Yokukansan
    https://www.ncbi.nlm.nih.gov/pubmed/27071791
    It is used to trea Alzheimer too
    https://onlinelibrary.wiley.com/doi/pdf/10.1111/jdi.12297

    ReplyDelete
  11. Peter, I think about corn silk extract as a natural replacement for bumetanide. It has some common properties: lowering potassium and diuretic.
    https://www.mdpi.com/1420-3049/17/8/9697/htm?&utm_medium=110724
    https://www.ncbi.nlm.nih.gov/pubmed/15638089
    I will get a try in summer time for my severely autistic daughter. Recently she accepted oral medicine by syringe, so I can supplement with adequate potassium.
    What do you think about corn silk? Thank you again for your work.

    ReplyDelete
    Replies
    1. Prada, I think all people with severe autism should trial an NKCC1 blocker. At the moment the only effective one that is widely available is Bumetanide. I could not see any reference that corn silk blocks NKCC1, even though it is a diuretic.

      Delete
  12. Peter, what do you think about red clover as phytoestrogen supplement,it acts on estrogenic receptors in brain and heart. I was thinking if it could increase estrogen levels in the brain and could be a good thing for my son. I don't know about cancer risk in this case as he is male and red clover only mimics estradiol.
    Valentina

    ReplyDelete
    Replies
    1. Valentina, there are many phytoestrogens, there is a debate as to how potent they really are compared to estradiol. Japanese people who have high consumption of soy/tofu do seem to have long term health benefits like long life expectancy and low rates of dementia.

      I think the brain specific estradiol pro-drug is very interesting, but for the moment acquiring a taste for Japanese food, like the Okinawa Diet, is a good idea.

      Buying supplements as a source of estrogen, is not reliable. You might as well buy estradiol tablets.

      Delete
  13. For people with the PTEN macrocephaly profile of autism, some new research suggests a compound found in broccoli (not sulphuraphane) can help upregulate PTEN expression:

    Press Release:

    https://www.sciencedaily.com/releases/2019/05/190516142913.htm

    Paper:

    https://science.sciencemag.org/content/364/6441/eaau0159

    The compound in question is called indole-3-carbinol and even though this research is for cancer where PTEN activity is often downregulated, the research I believe has obvious potential dual uses for autism. The press release mentioned that you would need to eat 6 pounds of brussel sprouts a day to get enough indole-3-carbinol so synthesizing it or else sacrificing a bunch of brussel sprouts for an extract would be necessary. Unfortunately, if a drug is created based on this research, considering this would be a drug primarily for cancer, it will obviously be prohibitively expensive until patents run out. I know there are broccoli/brussel sprout extract supplements, but I don't know how much indole-3-carbinol is supplied, especially since many of them focus on sulphuraphane content and the purification process may destroy the indole-3-carbinol (really I don't know, maybe somebody else here who reads this blog has a better idea).

    ReplyDelete
    Replies
    1. Tyler, this old posts has some relevance here.

      https://epiphanyasd.blogspot.com/2014/11/is-dj-1-expression-negatively.html

      It looks at DJ-1, broccoli and indeed statins as regulators of PTEN.

      I think it is far from clear which benefit some people with autism experience from broccoli.

      Delete
    2. Peter, apparently, I was mistaken about indole-3-carbinol in that it has been a very popular supplement you can buy relatively cheaply online or in a vitamin store. Its most popular use seems to be in the fat loss category as it is anti-estrogenic which is also why it seems to also be good at helping to prevent breast cancer or at least decreasing the risk factors of breast cancer. Strangely, it also seems to raise testosterone, yet it is also seems to be very good with regards to prostate cancer. From what I could briefly read about its bioavailability, there is no clear answer as one study suggested no detectable serum levels of indole-3-carbinol after ingestion, while others have shown the many hypothesized effects such as lower estrogen metabolites and higher testosterone metabolites from oral use.

      Considering you can get this supplement OTC and that it has been around for quite a while apparently, it might be worth looking at.

      Also, I did a quick search for indole-3-carbinol and autism and another blog post of yours from 2014 popped up as third on the search:

      https://epiphanyasd.blogspot.com/2014/10/

      Unlike sulphuraphane, I don't believe indole-3-carbinol requires myrosinase to be absorbed, but again the bioavailability questions are still there. I could not find any studies linking indole-3-carbinol and autism, just a few blogs and popular science articles speculating on the connection between its PTEN upregulation properties and PTEN being a major autism gene.

      Also, I thought you might be interested in this recent research looking at another way microglia can become inflamed.

      https://med.stanford.edu/news/all-news/2019/05/blocking-protein-curbs-memory-loss-in-old-mice.html

      This research looks at what causes old animals (mice in this study) to lose their memory as they get older. Activated microglia, just as in autism, seem to play a big role in neurodegenerative disorders like Alzheimer's and Parkinson's disease and it was found that by blocking one particular protein (VCAM1) classically involved in allowing immune cells past the blood brain barrier, that old mice gained memory functions equivalent to their younger selves.

      Now what effect this would have in some autisms is something I am not sure about and whether activated microglia are merely the cause or effect of some of the problems in the brain in autism obviously has no consensus on at the moment so reducing immune cell entry into the brain would prevent excess inflammation, or whether the immune cells are actually needed to help fight some other endemic problem like a persistent viral infection in the brain or else some parasite like toxoplasmosis that if left unchecked can cause extreme harm such as in infants and those with already compromised immune systems such as AIDS patients.

      Delete
    3. Also here is another very interesting study on schizophrenia and glutamate whereas the researchers were able to successfully improve mGlur5 signaling in the brain via sulphuraphane treatment:

      Press Release:

      https://www.sciencedaily.com/releases/2019/05/190508093733.htm

      There are three different papers provided in the links so I won't repost them. The interesting thing here is they first found that glutathione was being used as a gas tank for glutamate storage and that in schizophrenia, the presynaptic mglur5 receptors were not being activated because the glutathione stores were being used up too fast (or rather not replenished enough or in sufficient quantities). Sulforaphane seemed to rescue this problem as it increased glutathione levels by 30% in the brain (NAC obviously would likely help too as it has been used for schizophrenia for a very long time).

      Also, another study on repetitive behaviors (in roundworms) is very interesting in that it showed excess glutamate release from roundworm glial cells that are roughly equivalent to human astrocytes induced repetitive behaviors:

      Press Release:

      https://www.sciencedaily.com/releases/2019/05/190511083934.htm

      Paper:

      https://www.nature.com/articles/s41467-019-09581-4

      mglur5 hyperactivity in the striatum has been linked several times to repetitive behaviors as well. Now, if there is already excessive glutamate spillover at mglur5 synapses, the question begs as to whether glutathione boosting via sulforaphane or NAC could contribute to worse repetitive behaviors, even though other positive contributions from sulforaphane and NAC might ameliorate other negative autism behaviors.

      Obviously, reducing extracellular glutamate would be the most desirable here as it seems boosting intracellular glutamate reserves with glutathione is usually desirable, but if extracellular glutamate is not reduced, then the question is do repetitive behavior symptoms get worse? The glutathione-glutamate paper suggests glutathione only gets used as a glutamate reserve when the glutamate-glutamine shuttle gets exhausted, so in that case NAC/Sulforaphane would not cause problems, but nevertheless these are some interesting questions that would be helpful to resolve, especially since my first trial run with sulforaphane products a while ago ended up with hyperactivity (this is just what I observed and a second run with my son using a different product did not produce this effect so I am only speculating here).

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    4. Tyler, thanks. All very interesting.

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    5. Thanks Tyler for this article on glutathione as a storage for glutamate - highly interesting!
      I can't follow your hypothesis that sulforaphane/NAC could induce repetitive behaviour though. My reading is that these substances reduce excitotoxicity by 1)reducing non-bound glutamate 2)boosting oxidative defense.
      Sulforaphane probably does a lot of other things in the brain as well, and maybe one of those is guilty of your son's hyperactivity?
      Which brand worked for you and which didn't?

      /Ling

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  14. Petra, did you ever try low dose naltrexone for your son?
    ~Tanya

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    1. Hi Tanya, Sorry I am late for my reply, no I have no experience with LDN. I know some people use it for self injury and depersonalisation treatment, are you facing such challenge?
      Petra

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    2. Well my over achiever oldest son at university, not the one with autism, had a major depressive episode and was in the hospital for a few days. The doctor prescribed low dose naltrexone for what turned in to debilitating compulsive behaviors. I renembered you mentioning the looping thoughts with your son and just wondered if you tried it. Now I wonder if it will help my son with autism. He has done so well with lithium but still has some impulsivity/addictive type issues.
      Thanks for your reply and how is your son doing ? Hope all is well
      ~Tanya

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  15. Old mother with autoimmune issues and a child with genetic pathology is considering the risks related to having another child. Any advice on what can be done to lower the risks, before a final decision is made on how to proceed, would be highly valued. -Anonymous

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    1. One take away point from the week end autism conference in London was that "the baby's microbiome comes from the mother". This you can improve before the baby is conceived and that will lower the risks the child may face.

      One very serious idea is to expose the future mother to the bacteria evolution has programmed us to expect. So keep a dog inside your house and don't overly worry about him crawling all over your furniture, what you want is "doggy dust" in your house. Go to the countryside visit farms with chickens, cows sheep etc. That you way you will pick up bacteria your body was programmed over thousands of years to expect. This helps calibrate the immune system of the baby before it is born.

      You also want to minimize all forms of stress, behavioural, emotional and biological. The best way is to take it easy and do not work.

      Do not be overweight. Avoid delivery by C-section if possible. Avoid gestational diabetes. Make sure your hormones before pregnancy and during are within the normal range.

      Make a huge effort to have a really healthy diet with fruits, berries, vegetables of all colours. Olive oil, mediterranean herbs , no alcohol no smoking, no prescription drugs, no alternative supplements etc.

      Ideally have a younger father !

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    2. Thank you Peter! What about NAC?
      -anonymous

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    3. In healthy middle aged people giving antioxidants has been shown to be counterproductive. Your body has its own antioxidants like GSH. If you give extra antioxidants it just makes your body stop producing its own, to maintain homeostasis.

      In sick people and old people their body does not produce enough antioxidants. You can actually check your status by measuring the GSH:GSSG ratio in your blood.

      So if you are healthy enough to consider another child you will not need NAC.

      All drugs and supplements have secondary effects and should be avoided if you want another child, unless it is expressly deemed necessary by your doctor.

      Hopefully you do not have epilepsy, because anti-epileptic drugs clearly will affect the developing brain of the child.

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    4. (1) Take prenatal vitamins fortified with folic acid especially before you try and conceive as well as after you know you have conceived.

      (2) There is very recent research that Nicotanimide Riboside can be very beneficial for the baby and the mother, especially older others who have low NAD+ levels. Besides the B vitamins which includes folic acid, I would say this would be a very important one if you can afford the dollar a day cost even though human research on its effects during pregnancy don't exist yet. I would take NR if I were a woman trying to conceive, especially if I were older.

      (3) If yout can't ensure your fruits and vegetables are not thoroughly cleaned, rewash them to remove as many pesticides, bacteria and other microorganisms as possible. You don't need to go crazy about this, just that infections and sickness or anything causing an immune challenge can be deleterious to the baby.

      (4) Just as smoking delivers carcinogens to the lung in the form of charred carbon, you might want to avoid excessively cooked meat as well as processed meats which are usually overcooked as well and contain many carcinogens. Of course undercooked meat can lead to problems as well so just don't overdo it or underdo it when it comes to cooking and eating meat.

      (5) There is no safe level of alcohol for the baby period. In the United States the rate of fetal alcohol syndrome is higher than that of autism, though autism gets far more attention. Even a small amount fron one night of imbibing at a critical time early in the pregnancy can ruin your child for life. If I was dictator I would say alcohol should be illegal for women of childbearing age because the damage from gestational alcohol exposure is incredible when you look at the statistics, and that does not even include the average reduced IQ of a population from alcohol exposure in the womb from children harmed from alcohol, but not so severely that they have a FASD diagnosis.

      (6) Regular exercise before, during, and after pregnancy will greatly improve the health of the baby and the quality of the pregnancy. There is a myth that women need to be sitting around on a couch with a pint of Haagen Dasz when in fact until recent history, everyone in the family had to do some level of physical labor to contribute to the family economy. Maybe they didn't strap on some armor and go get themselves and their baby killed in hand to hand combat in some war as one would believe in modern cinema, but women have always had to do physical work that required moving around. Ironically, in recent times with female employment at an all time high in desk jobs, many pregnant women are putting their child at risk from their lack of physical activity from their butt in seat jobs. In less developed countries, women contribute a lot more to their families than here in the west and that physical activity is superior to trying to make up for a sedentary lifestyle with a few yoga classes.

      (7) Sleep. Everybody knows this yet nobody does this. It seems like western women have taken all the terrible habits of men which includes working too hard and sleeping too little and the future generations have to suffer for it. When it comes to sleep and pregnancy, women need to be selfish these days. If your husband is not agreeable, well then he is just ignorant. Also, taking time off from a stressful job after the delivery does the baby no good while he/she is in the womb.

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    5. Thank you so much for the effort to put down all these advice for me, and my potential baby if I decide to go through. It is not an easy decision, knowing all the risks. -anonymous

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  16. Hello Peter,

    Based on the literature you've read, would you expect furosemide to have an equally potent (dosage-adjusted) effect as bumetanide on neuronic chloride levels?

    Considering factors like BBB availability, the outflow reduction effect you mentioned, and other potential differences between the two drugs, I'm not sure how viable of an option it would be.

    I ask mainly because I've been getting verapamil imported through an online pharmacy (our doctor isn't trusting enough to prescribe our son off-label heart medications), and the site we use doesn't seem to carry bumetanide, but does have furosemide in stock.

    Thank you,
    - Jon

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    Replies
    1. Jon, the literature shows that furosemide is highly unlikely to work. It is much weaker than bumetanide at blocking chloride entering neurons and it actually accelerates how fast they can leave.

      Many people are buying Bumetanide on line from Mexico. So maybe that is helpful to know. You will find it, if you keep looking.

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